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. i <br /> UST SYSTEM RETROFIT OR REPAIR <br /> (Submit minimum of 2 sets of plans &applications as originals will be retained by EHD) <br /> 1. Site map enclosed YES [] NO[ell <br /> 2. Manufacturer's spec sheets attached for all equipment to be installedYES[] NO[e <br /> 3. Description of work to be completed (If addin_q piping, UDC's, or other UST equipment, or performing tank top upgrade; <br /> use the UST Installation Application page 4-8 a3j necessary for a timely plan review), 1 <br /> �eGrGr�XGfJIarS ri Airee ✓1K <br /> 4, Description of equipment to be u ed (Attach drawings/blueprints as necessary): <br /> t�Cr�,o e,r r lice{� <br /> 5. All equipment is State certified or approved. YES 1440 [] <br /> 6. Decontamination Procedures: <br /> a. Will piping be decontaminated prior to removal? YES[] NO [] <br /> b. Identify contractor perfo( ing decontamination: <br /> Name \\ PhoneL_) <br /> Address City Zip <br /> C. Describe method to be used r decontamination: <br /> d. Describe how rinsate material will be toned onsite prior to manifesting offsite: <br /> e. Rinsate Hauler and permitted Treatment, St rage& Disposal Facility <br /> Hauler Name phone(. ) Hauler Reg# <br /> Address \ City Zip <br /> Permitted Disposal Site <br /> 7. a, Describe the method that will be utilized to purge anclh r inert e piping.- <br /> b. <br /> iping:b. Piping Hauler: <br /> Name Phone <br /> Address City Zip <br /> Hauler Registration#(if hauled as hazardous) <br /> c. Piping Disposal Site, <br /> Name \ Phone L__j <br /> Address City Zip <br /> EPA ID#(if transported to a permittedTS facility) <br /> 8. is the sampling firm an independent t ' d party from the contractor? YES4] NO[] <br /> 9. Describe, in detail; how the soil an or water sample(s) beneath the piping qr dispenser will be obtained: <br /> 10. Handling of excavated soil ontaminated Soil Hazardous Waste Hauler)' <br /> Name Hauler Registration# Phone (�� <br /> Address City Zip <br /> b) If soil is not to be 41ed, describe what will be done with it. <br /> 2 <br /> 90/'90 39vd 11IH i10FIHO CZ96EGET99 ZT :ZZ 800Z/T0/S0 <br />